Failure to Monitor and Promptly Evaluate Change in Condition After Resident Injury
Penalty
Summary
The facility failed to ensure appropriate monitoring and prompt medical evaluation for a resident who experienced a change in condition following an incident involving their right ankle. The resident, who had a history of generalized muscle weakness and cauda equina syndrome and was cognitively intact, reported injuring their right foot when their ankle-foot orthosis became caught on a store display while using a motorized wheelchair outside the facility. Upon return, the resident reported the incident and pain to a physical therapist, who performed passive range of motion but did not notify nursing, as the resident was not on the therapy caseload. The resident later reported pain to a CNA, who notified a nurse. The nurse documented the pain and administered oxycodone, noted the incident in the communication book, and placed the resident on alert charting for monitoring. Despite the initial documentation, there was no evidence of continued alert charting or provider assessment for the resident's right ankle pain over the following three days. The resident continued to receive pain medication and non-pharmacological interventions such as rest and cold/ice, but there was no documentation of ongoing monitoring or follow-up assessments by nursing or the medical provider during this period. The facility's policies required prompt notification of the provider and ongoing documentation for changes in a resident's condition, but these were not followed. The lack of communication between therapy and nursing, as well as the absence of continued monitoring, resulted in a delay in medical evaluation. Eventually, the resident was assessed by a provider, who ordered an x-ray that revealed a right tibial fracture, leading to the resident's transfer to the hospital. During hospitalization, the resident was also diagnosed with a left leg deep vein thrombosis and acute pulmonary embolism, conditions attributed to immobilization following the fracture. Interviews with facility staff confirmed that the expected procedures for monitoring and documentation were not followed, and the incident was not communicated effectively among the interdisciplinary team. The facility's internal investigation corroborated that the resident was not placed on alert charting as required, and there was no evidence of timely provider follow-up.